Mortality-related factors disparity among Iranian deceased children aged 1-59 months according to the medical activities in emergency units: National mortality surveillance system

Article (PDF Available)inJournal of research in medical sciences 17(12):1096-101 · December 2012with29 Reads
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To determine disparity in mortality-related factors in 1-59 months children across Iran using hospital records of emergency units. After designing and validating a national questionnaire for mortality data collection of children 1-59 months, all 40 medical universities has been asked to fill in the questionnaires and return to the main researcher in the Ministry of Health and Medical Education. Age and sex of deceased children, the type of health center, staying more than 2 h in emergency unit, the reason of prolonged stay in emergency, having emergency (risk) signs, vaccination, need to blood transfusion, need to electroshock and so on have also been collected across the country. There was also a comparison of children based on their BMI. Chi-square test has been applied for nominal and ordinal variables. ANOVA and t-student test have been used for measuring the difference of continuous variables among groups. Mortality in 1-59 months children was unequally distributed across Iran. The average month of entrance to hospital was June, the average day was 16(th) of month, and the average hour of entrance to hospital was 14:00. The average of month, day and hour for discharge was July, 16, and 14:00, respectively. The hour of discharge was statistically significant between children with and without risk signs. More than half (54%) of patients had referred to educational hospital emergency units. There were no statistically significant differences between children with and without emergency signs. There were statistically significant differences between children with and without emergency signs in age less than 24 months (0.034), nutrition situation (P = 0.031), recommendation for referring (P = 0.013), access to electroshock facilities (P = 0.026), and having successful cardiopulmonary resuscitation (P = 0.01). This study is one of the first to show the distribution of the disparity of early childhood mortality-related factors within a developing country. Our results suggest that disparity in 1-59 months mortality based on hospital records in emergency units needs more attention by policy-makers. It is advisable to conduct provincially representative surveys to provide recent estimates of hospital access disparities in emergency units and to allow monitoring over time.
Journal of Research in Medical Sciences
| July 2012 |
Original article
Prevalence study of clinical disorders in 6-year-
old children across Iranian provinces: Findings of
Iranian national health assessment survey
Masoud Amiri, Roya Kelishadi
, Mohammad E. Motlagh
, Mahnaz Taslimi
, Majzoubeh Taheri
, Gelayol Ardalan
Parinaz Poursafa
Social Health Determinants Research Center and Department of Epidemiology and Biostatistics, School of Health, Shahrekord University of
Medical Sciences, Shahrekord,
Department of Pediatrics, School of Medicine and Children’s Growth and Development Research Center,
Isfahan University of Medical Sciences, Isfahan,
Bureau of Population, Family and School Health, Ministry of Health and Medical Education,
Bureau of Health and Fitness, Ministry of Education and Training, Tehran, Iran
Objective: To assess the national prevalence of clinical disorders in 6-year-old Iranian children before school entry using a national
health assessment survey. Materials and Methods: In a cross-sectional nationwide survey, all Iranian children entering public and
private elementary schools were asked to participate in a mandatory national screening program in Iran in 2009 in two levels of
screening and diagnostic levels. Results: e study population consisted of 955388 children (48.5% girls and 76.1% urban). Of the
whole children, 3.1% of the 6-year-old children had impaired vision. In addition, 1.2, 1.8, 1.4, 10, 10.9, 56.7, 0.7, 0.8 and 0.6% had color
blindness, hearing impaired, speech disorder, height to age retardation, body mass index extremes, decayed teeth, having disease with
special needs, spinal disorders, and hypertension, respectively. e distribution of these disorders was unequally distributed across
provinces. Conclusions: Our results confirmed that the prevalence of clinical disorders among 6-year-old children across Iranian
provinces was not similar. e observed burden of these distributions among young children needs a comprehensive national policy
with evidence-based province programs to identify the reason for different distribution among provinces.
Key words: Children, clinical symptoms, Iran, national health assessment survey, prevalence
Address for correspondence: Prof. Roya Kelishadi, Department of Pediatrics, School of Medicine and Children’s Growth and Development
Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail:
Received: 28-03-2012; Revised: 14-05-2012; Accepted: 20-05-2012
considered all Iranian provinces.
Some of these
studies were only on adult people
or only on
special disease such as childhood dental problems
or overweight and obesity.
Moreover, developing
countries including Iran are facing with epidemiologic
transition in disease and nutritional paerns
in turn would raise the necessity for conducting a
representative and comprehensive national health
survey. Since Iran is a big country, taking into account
the great diversity in socioeconomic and demographic
factors in dierent provinces, it is expected to observe
a substantial inequality in disease and disorder
distribution across Iranian provinces. The aim of this
study is to assess the potential dierence of national
prevalence distribution of clinical disorders distribution
among 6-year-old Iranian children before school
entry across Iranian provinces using national health
assessment survey.
The data were collected as a nationwide screening
program in a cross-sectional study. This program is
regularly performed by the Ministry of Health and
Medical Education and the Ministry of Education and
Training among all children entering elementary schools.
Representative and valid information at the population
level is essential for health planning and priority
seing for interventions to control diseases, and for
population-based evaluation of health programs.
National representative studies may help us to have a
view on these health concerns at national and regional
levels. There have been conducted many national health
surveys worldwide to prepare reliable information for
policy making.
Although, there are some Iranian health surveys
available, which most of these previous studies have
been limited to one city and thus their results could not
be generalizable to the whole country;
there are also some national studies which have been
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Journal of Research in Medical Sciences
| July 2012 |
Amiri, et al.: Screening of clinical disorders in Iranian children
All Iranian children entering elementary school were studied.
As in Iran, elementary education is mandatory; thus, the study
population comprised all children entering public and private
elementary schools. During summer 2009 (for three months),
in 823 centers and 712 cities and regions, 955388 Iranian
children entering elementary schools have been assessed
physically and mentally by 5582 skilled health care sta.
The assessment had two levels: introductory (screening)
and diagnostic levels. In the rst level, probable diseases
and disorders have been screened (in 13 dierent aspects)
and potential patients were sent to verify their possible
problems in the second level. The diagnosed patients
then were referred to specialists for further treatment and
some advices were given to their parents. Ethical concerns
have been considered by the aforementioned ministries.
The national Data and Safety Monitoring Board closely
supervised the quality control and quality assurance of each
survey. At rst, the data-checking process was conducted
at the provinces every week and then at national level
monthly. The analysis has been done aer editing.
Training sessions were organized for health-care providers
who measured children’s weight and height according to
standard protocols by using calibrated instruments. Body
mass index (BMI) was computed as weight in kilograms
divided by the square of height in meters. In all surveys,
the growth charts of the Centers for Disease Control and
Prevention were used,
which are in close agreement with
Iranian charts.
Overall health assessment, impaired vision (negative,
positive, no corporation and unknown), color blindness
(negative, positive, unknown), hearing impaired (negative,
positive, no corporation and unknown), speech problems
(negative, positive and unknown), appearance situation
(anemic, cyanosed and edema), skin and hair (scabies and
scalp ringworm), glands (hyperthyroidism and enlarged
lymph nodes), eye problems, ear problems, deviated nasal,
abnormal mucosa, adenoid, abnormality in height to age ratio
and BMI, decayed teeth, having disease with special need
for surveillance, hypertension (systolic: <70 and 120+, and
diastolic: <20 and 100+), spinal situation (spinal disorders,
kyphosis, lordosis, scoliosis, walking abnormalities and
flat feet), abdomen (abdominal mass, enlarged spleen,
hepatomegaly and hernia), chest (cardiovascular, thorax
and lung diseases), genitourinary (genital ambiguity,
undescended testicles, hernia, hydrosol and renal diseases),
neurologic problems and puberty (precocious and delayed)
were the considered health problems which were taken into
account by general practitioner.
The children with potential disorders have been referred to
specialists. The specialists have taken into account overall
assessment (healthy or ill), vision examination (no problem,
no glasses needed for now, glasses needed, amblyopia,
medication-surgery supervision, vision-aid instrument (sent
to normal school), vision-aid instrument (sent to special
school) and blind), hearing examination (no problem,
duct collapse, medical treatment, ear wash, one-sided ear
problem, problem in one or two frequency, problem in low
frequency, hearing-aid instrument (sent to normal school),
hearing-aid instrument (sent to special school) and deaf),
having both vision and hearing problems (sent to normal
or special schools), dermal problems (head lice and scalp
ringworm), dental problems (decayed, missed and lled
teeth and gingivitis), special diseases (diabetes mellitus,
cardiovascular diseases, epilepsy, asthma, hemophilia and
Thalassemia), positive family history (diabetes mellitus,
hypertension, smoking, atherosclerosis, tuberculosis,
asthma, hemophilia, Thalassemia, seizure disorder, mental
disorders and others), positive personal history (diabetes
mellitus, hypertension, atherosclerosis, tuberculosis,
asthma, hemophilia, Thalassemia, seizure disorder, mental
disorders and others), need for special surveillance (no,
yes and unknown), medication use history (no, yes and
unknown) and sensitivity history (no, yes and unknown).
The data were analyzed using the Statistical Package
for Social Sciences (SPSS) soware package version 18.0
(SPSS Inc., Chicago, IL, USA). The absolute and relative
frequencies of variables were obtained and demonstrated
in Tables 1-3.
Table 1: Main characteristics of national health
assessment survey on Iranian 6-year-old children before
entering school
Characteristics Number (%)
Health employees 5582 (-)
Girl 463076 (48.5)
Boy 484891 (50.8)
Urban 727309 (76.1)
Rural 210997 (22.1)
Health insurance
Yes 714955 (74.8)
No 233755 (24.5)
Home language
One 673812 (70.5)
Two 273708 (28.6)
Complete 817995 (85.6)
Incomplete 110234 (11.5)
Extra/specific examination
Not necessary 757950 (79.3)
Necessary 26702 (2.8)
Unknown 170736 (17.9)
Refer to specialists 146790 (15.4)
Refer to special schools 4661 (0.5)
*Some sum of percentages is not 100% due to unknown data
Journal of Research in Medical Sciences
| July 2012 |
Amiri, et al.: Screening of clinical disorders in Iranian children
Table 2: Main clinical disorders of national health
assessment survey at primary assessment among
Iranian 6-year- old children before entering school
Disease/disorder Number (%)
Overall primarily assessment
Healthy 809593 (84.7)
With disease/disorder 39859 (4.2)
Unknown 105936 (11.1)
Impaired vision
Negative 912931 (95.6)
Positive 29874 (3.1)
No corporation 4544 (0.5)
Unknown 8039 (0.8)
Color blindness
Negative 028231 (97.2)
Positive 11243 (1.2)
Unknown 15914 (1.7)
Hearing impaired
Negative 926505 (97.0)
Positive 16821 (1.8)
No corporation 3523 (0.4)
Unknown 8539 (0.9)
Speech problems
Negative 219957 (95.9)
Positive 13586 (1.4)
Unknown 25845 (2.7)
Clinical assessment results
Appearance situation
Anemic 3618 (3.3)
Cyanosed 176 (<0.1)
Edema 229 (<0.1)
Skin and hair
Scabies 470 (<0.1)
Scalp ringworm 354 (<0.1)
Hyperthyroidism 2670 (0.3)
Enlarged lymph nodes 2824 (0.3)
Eye problems 5447 (0.6)
Ear problems 5398 (0.6)
Deviated nasal 1130 (0.1)
Abnormal mucosa 1339 (0.1)
Adenoid 9271 (1.0)
Height to age ratio (abnormality) 95587 (10)
Body mass index (BMI) abnormality 104161 (10.9)
Decayed teeth 541971 (56.7)
Having disease with special surveillance 6798 (0.7)
Problems in hair, skin, glands, and E. N. T 60926 (6.4)
Hypertension 5613 (0.6)
Systolic pressure
<70 3993 (0.4)
120+ 504 (0.1)
Diastolic pressure
<20 493 (0.1)
100+ 623 (0.1)
Spinal situation
Spinal disorders 8045 (0.8)
Kyphosis 230 (<0.1)
Table 2: cond...
Disease/disorder Number (%)
Lordosis 630 (0.1)
Scoliosis 433 (<0.1)
Walking abnormalities 1332 (0.1)
Flat feet 5420 (0.6)
Abdominal mass 187 (< 0.1)
Enlarged spleen 214 (< 0.1)
Hepatomegaly 143 (< 0.1)
Hernia 1060 (0.1)
Cardiovascular 4269 (0.4)
Thorax 800 (0.1)
Lung 1496 (0.2)
Genital ambiguity 278 (< 0.1)
Undescended testicles 2261 (0.2)
Hernia 762 (0.1)
Hydrosol 470 (< 0.1)
Renal 1418 (0.1)
Neurology 1829 (0.2)
Precocious 952 (0.1)
Delayed 193 (< 0.1)
*Some sum of percentages is not 100% due to unknown data
Main characteristics of national health assessment survey
on Iranian 6-year old children before entering school in
2009 are shown in Table 1. The number of health employees
who helped to conduct this survey was 5582 health works
through Iran. Of 955388 Iranian children aged 6-year old,
463076 (48.5%) children were girls, 727309 (76.1%) lived in
urban area, 233755 (24.5%) did not have health insurance,
237808 (28.6%) spoke two languages at home, 110234
(11.5%) did not complete their vaccination, 146790 (15.4%)
children were referred to specialists and 0.5% had to go to
special schools.
Table 2 demonstrates the main clinical symptoms of these
children reported by general practitioners. Of these children,
809593 (84.7%) were healthy. In addition, 3.1, 1.2, 1.8 and 1.4%
had impaired vision, color blindness, hearing impaired and
speech problems, respectively. Abnormalities in height to
age ratio and body mass index (BMI) have been observed in
10.0 and 10.9% of Iranian children entering primary school,
respectively. Furthermore, decayed teeth, having disease
with special surveillance need, problems in hair – skin –
glands - and ear – nose - and throat (ENT), spinal disorders
and hypertension were observed in 56.7, 0.7, 6.4, 0.8, and
0.6% of Iranian children in 2009. Moreover, appearance
of 3.3% of children was anemic, while only less than 0.1%
of these children were cyanosed or edema, respectively.
Less than 0.1% of children has showed scabies and scalp
Table 2: cond...
Journal of Research in Medical Sciences
| July 2012 |
Amiri, et al.: Screening of clinical disorders in Iranian children
ringworms. Hypothyroidism and enlarged lymph nodes
were diagnosed in 0.3% of children. Eye, ear, deviated nasal,
abnormal mucosa and adenoid were reported in 0.6, 0.6, 0.1,
0.1 and 1.0% of Iranian 6-year children. Hypertension was
in 5613 (0.6%) of children, with 0.4, 0.1, 0.1 and 0.1% with
systolic blood pressure less than 70 and above 120 mmHg,
and diastolic blood pressure less than 20 and more than 100
mmHg, respectively. Spinal disorders were diagnosed in
8045 (0.8%) of children. Abdomen, chest, genitourinary and
puberty disorders were reported in less than 1000 children.
Main clinical disorders found by specialists are presented
in Table 3. Most of the children who have been sent to
specialists were healthy. Many of the children needed
glasses to have a better vision. There were also many
hearing problems among these children. Some children had
combination of visual and hearing problems. There was also
head lice and scalp ringworm among Iranian 6-year-old
children. Some special diseases such as diabetes mellitus,
cardiovascular diseases have also been reported. For some of
these diseases, there was a familial and/or personal history.
To the best of our knowledge, the present study is one of
the rst Iranian reports providing information on national
prevalence of clinical disorders from the entire population
of children at school entry. We confirmed substantial
Table 3: Main ndings of specialists on clinical
disorders of national health assessment survey among
Iranian 6-year- old children before entering school
Disease/disorder Number (%)
Overall specialist assessment
Healthy 51367 (5.4)
Ill 4533 (0.5)
Vision examination
No problem 4435 (19.2)
No glasses needed for now 4350 (18.8)
Glasses needed 9300 (40.1)
Amblyopia 4202 (18.1)
Medication-surgery supervision 600 (2.6)
Vision-aid instrument (normal school) 172 (0.7)
Vision-aid instrument (special school) 79 (0.3)
Blind 35 (0.2)
Hearing examination
No problem 3684 (26.9)
Duct collapse 1853 (13.5)
Medical treatment 2369 (17.3)
Ear wash 2196 (16.0)
One-sided ear problem 857 (6.3)
Problem in one or two frequency 1663 (12.1)
Problem in low frequency 636 (4.6)
Hearing aids (normal school) 254 (1.9)
Hearing aids (special school) 127 (0.9)
Deaf 69 (0.5)
Having both visual and hearing problems
Sent to normal school 975 (7.7)
Sent to special school 73 (0.6)
Dermal problems
Head lice 4201 (0.4)
Scalp ringworm 384 (<0.1)
Dental problems
Decayed teeth 541971 (56.7)
Gingivitis 8604 (0.9)
Missed teeth 79100 (8.3)
Filled teeth 64229 (6.7)
Special diseases
Diabetes mellitus 232 (<0.1)
Cardiovascular diseases 1304 (0.1)
Epilepsy 1111 (0.1)
Asthma 2424 (0.3)
Hemophilia 215 (<0.1)
Thalassemia 1512 (0.2)
Need for special surveillance
No 796272 (83.3)
Yes 11756 (1.2)
Unknown 14736 (15.4)
Positive family history for
Diabetes mellitus 8416 (0.9)
Hypertension 9354 (1.0)
Smoking 92216 (9.7)
Atherosclerosis 4508 (0.5)
Tuberculosis 240 (<0.1)
Asthma 4712 (0.5)
Table 3: cond...
Disease/disorder Number (%)
Hemophilia 190 (<0.1)
Thalassemia 3796 (0.4)
Seizure disorder 2593 (0.3)
Mental disorder 5318 (0.6)
Others 19710 (2.1)
Positive personal history for
Diabetes mellitus 320 (< 0.1)
Hypertension 199 (< 0.1)
Atherosclerosis 202 (< 0.1)
Tuberculosis 125 (< 0.1)
Asthma 3452 (0.4)
Hemophilia 210 (< 0.1)
Thalassemia 2260 (0.2)
Seizure disorder 4537 (0.5)
Mental disorder 2355 (0.2)
Others 10913 (1.1)
Medication use history
No 789333 (82.6)
Yes 15545 (1.6)
Unknown 150510 (15.8)
Sensitivity history
No 776634 (81.3)
Yes 28241 (3.0)
Unknown 150513 (15.8)
*Some sum of percentages is not 100% due to unknown data
Table 3: cond...
Journal of Research in Medical Sciences
| July 2012 |
Amiri, et al.: Screening of clinical disorders in Iranian children
dierences in the regional distribution of diseases and
disorders across Iranian provinces.
Since various socioeconomic groups are living in dierent
provinces and therefore the observed dierences among
provinces on children disorders and diseases cannot be fully
explained by the socioeconomic paern of each province, this
study has not documented the socioeconomic determinants
of growth in Iranian 6-year-old children at school entry. As
an obvious assumption, it seems to be logical to say that the
provinces with the more prevalence of diseases/disorders
were economically deprived; however, this prevalence was
low in other provinces with a similar socioeconomic situation.
The irregularity in distribution of diseases/disorders across
Iranian provinces does not follow the socioeconomic
distribution. It means that there is a considerable inequality
in the distribution paern of diseases/disorders. The rst
explanation for this inequality would be dierent nutritional
and economical paerns among Iranian provinces; however,
because in recent decades, Iran has had a big improvement
in maternal and child nutritional status,
the role of other
determinants such as the dierent paern of micronutrient
distribution across Iran might be more important; in other
words, it might be due to recent global economic crisis
which it could aect on the accessibility of Iranian families
to the enough and necessary amount of foods.
Another explanation for the observed inequality might be
the ethnic dierences. The populations of various Iranian
provinces have their own ethnic distribution. However,
these dierences are more socioeconomic-related than ethnic
dierences, because even in provinces with a mixture of ethnic
groups, the distribution of observed diseases/disorders i